Health Information Management

Q&A: Present on admission claims and the "U" indicator

CDI Strategies, January 24, 2008

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Q: We understand that codes that do not include a present-on-admission (POA) indicator will be returned to us as of April. Will CMS return claims that include a code for which we report a POA indicator of "U"? Or will CMS only return claims that include a blank POA field?

A: According to CMS' publications, as of April, it will only return those claims that do not include a POA indicator. If your system is set up to require a POA indicator for each diagnosis, you shouldn't have a problem.
 
Regarding the "U" indicator, CMS does state that the provider must resolve issues related to inconsistent, missing, conflicting, or unclear documentation. I interpret this as meaning that you should clarify insufficient documentation. If you clarify your documentation through physician queries, you should assign a very limited number of U indicators.

Editor's note: Sandy Nicholson, MA, RHIA, CCS-P, CEO of HCRSolutions, LLC, in Locust Grove, GA, answered this question.



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